The role of ethical frameworks

Biomedical ethics traces its origins at least to Hippocrates, who lived from about 460-370 b.c. The analysis of biomedical ethics is therefore older than Aristotle, older than Plato, and was going on for quite some time even before Socrates. So, we are engaging in a venerable tradition here.

Among the most famous of the ancient bioethical texts is the hippocratic oath, a promise that doctors have made for thousands of years, and which many still make today. (Read an English translation.)

But why believe these principles in not others? The hippocratic oath by itself is neither justified nor practical — there is no argument in favor of its prescriptions, and there is obviously little mention of many issues of practical relevance like comas, genetic testing, human research, or fairly distributing scarce resources. Although more modern oaths have also been developed (such as the declaration of Geneva, it seems likely that they too will some day fall out of date and remain without justification. More effective tools for dealing with ethical problems would be very helpful indeed.

We will review several different approaches to making ethical judgements today. There are many, many more. But fortunately, we do not have to choose just one in this course. We will proceed like shameless opportunists and use ethical frameworks as tools, in order to study and compare solutions to ethical problems in the biomedical sciences. We will test difficult each ethical problem using many different ethical frameworks in attempting to reach our own decisions about these matters.

There are three main frameworks that are of particular use in applied ethics. We will review each of them briefly in turn.

1. Consequentialism

Consequentialism is the view that one ought to act so as to give rise to the best consequences. Famous examples of consequentialist views are utilitarianism, which advocates maximizing "utility" according to some measure, and hedonism, which advocates maximizing pleasure and minimizing pain.

So, for example, say you saved up fifty pounds. You could go buy yourself another pair of shoes, or you could feed five homeless people breakfast, lunch and dinner. The second option is in many respects a better consequence, and so a consequentialist will likely advocate feedling the homeless.

One common concern about consequentialism is that it is often difficult to compare when one consequence/utility/pleasure is better than another. For example, how much money is needed to equal a human life? How many animal lives are needed to equal a human life? Questions like these do not have easy answers.

And, like all ethical frameworks, there are certain kinds of problems in which consequentialism draws strange conclusions. Compare two people, Alice and Bob. Alice is an extremely kind-hearted person who only wishes to do well to others. She carries out at least 10 acts a day that lead to good consequences. In contrast, Bob is extremely malifacent and only wishes to do harm to others. However, he is also astonishgly inept, and so by sheer accident happens to also do 10 good deeds a day. For example, he pushes an old lady out of contempt but accidently saves her from oncoming traffic. Now, one might like to say that Bob is in some sense worse than Alice. But according to consequentialism, the two are equally good, because they give rise to equally good consequences.

2. Deontology

Deontology comes from the Greek word deon meaning "duty" or "obligation." It is the view that one ought to act so as to conform or want to conform to some fixed values. For example, someone might live according to the deontological principle that one must never carry out a violent act. Unlike consequentialism, the concern is with the intention and the fulfillment of duty, rather than the consequences of an action. However, this does have the strange consequence that if (say) you could save someone's life by punching his attacker, you must not do so because it would violate the principle of non-violence.

There are other situations in which deontology can lead to strange consequences. For example, suppose some deranged criminal mastermind sets up a machine that will destroy all of Switzerland (and all the 8 million people that live there) unless you break your deontological rule, whatever it is. It might be ever-so-briefly, but you must break it if you wish to save the people. Here, the consequences are so incredibly bad that it is hard to imagine how it could be outweighed by any practical rule. In such cases, deontology sometimes founders.

3. Virtue Ethics

According to virtue ethics, one should seek to fulfill certain virtuous qualities, and act in whatever way those qualities require you to. An approach like this was advocated by Aristotle in Nicomachean Ethics. Some of his virtuous qualities like temperance and justice are still taught to doctors today, although modern problems in bioethics tend to focus on more informative qualities like trustworthiness, maintaining of privacy, and truthfulness.

A central difficulty with both virtues and deontological rules is that one is never enough, and that more than one often leads to contradictions. For example, the very influential 1979 Belmont Report in the United States advocated the following principles to guide medical ethical practice:

1. Respect for Autonomy - Let the patient make their own decisions.
2. Benefience and Non-maleficence - Do what's best for the patient and do no harm.
3. Justice - Be fair and equal in your actions.

However, these principles often go against one another. For example, respecting a patient's autonomoy might require you to tell him that he will very likely die this year, so that he can make his own decisions. But you may also know that this cause him harm, since he has a high propensity to become depressed and live out the remainder of his time much worse than he would had he not been told.

Mixing and Matching

This course will make no attempt to what the correct ethical principles are once and for all.

However, we will seek to formulate reasonable views on some very difficult cases in bioethics. By understanding several of these rules, keeping them in mind, and mixing and matching when you need to, you will be in a very good position to formulate your own view about these problems.